Division of Foot and Ankle Common Foot & Reconstruction Ankle Injuries • Adam T. Groth, MD • Kevin P. Martin, DO

• Timothy Miller, MD Adam T. Groth, MD • Julie Swain, APRN-CNP Associate Professor Chief, Division of Foot & Ankle Reconstruction • OSU Podiatry Jameson Crane Sports Medicine Institute Department of Orthopaedics • OSU Sports Medicine Family Medicine The Ohio State University Wexner Medical Center • OSU PM&R • OSU Physical Therapy

Acknowledgement Foot & Ankle Center of Excellence • Professor Emeritus Ian J. Alexander • Comprehensive care for all adult foot and ankle Disclosures problems:

• None • Sports injuries / Sprains / Cartilage disorders • Arthritis / Degenerative conditions • Deformities • Trauma / Fractures • Bunions / Hammertoes • Whatever is causing your pain

1 Common Problems of the Acute Ankle Sprain Foot & Ankle • Exceedingly common • Acute ankle sprains • 10-40% of civilian athletic injuries annually • Significant time lost to injury • Late pain after ankle sprains / associated injuries • 1 inversion event per 10,000 people per day • Stress fractures • 23,000 to 30,000 ankle injuries per day in U.S. • 10% or ER visits in U.S. • Achilles tendon ruptures • Plantar fasciitis • 45% of all basketball injuries • Bunions • 31% of collegiate football injuries • 20% of soccer injuries • Ankle arthritis • Leading cause of time loss in NFL • Most common cause of acute injury in volleyball

The Ankle Sprain Anatomy and Biomechanics • Mainstay of treatment is functional rehabilitation • 80% make a full recovery with conservative treatment

• 20-30% may be symptomatic 3 months after surgery

• Associated injuries may result in continued pain and

dysfunction Calcaneofibular Anterior Talofibular (CFL) • Repeat sprains or inadequate rehabilitation may (ATFL) result in chronic lateral instability in 20%

2 Mechanism Diagnosis

• Position of instability: • History of injury plantarflexion and inversion • Mechanism of injury • Talus is more narrow – Forces involved posteriorly – Direction of foot deviation • Failure occurs in predictable order • Prior episodes and frequency • Anterolateral capsule • ATFL (involved in 85%) • Immediate ability to weight bear • Restraint to inversion in PF • CFL (also injured in 20-40%) • Restraint to inversion in neutral or dorsiflexion • PTFL rarely injured

Examination of the Foot & Ankle Examination of the Foot & Ankle

•Examination • Examination – special tests • Be systematic (knee to toe) • Anterior drawer • Inspection / gait • Squeeze test – Ecchymosis and swelling • External rotation stress test – Localize tenderness » Soft tissue vs bony – Ambulatory capacity – Neurovascular exam – Range of motion

3 Anterior Drawer Are RADIOGRAPHS indicated? • Ottawa rules • Allow the leg to hang •ANKLE X-rays freely with foot plantarflexed 25° • Posterior tenderness distal 6 cm of tibia or • Stabilize the tibia with 1 fibula hand and grasp the heel • Malleolar tip tenderness with the other. • Both immediate inability to WB and not able • Pull foot anteriorly, “Sulcus sign” anterior to fibula allowing it to rotate to walk more than 4 steps in ED internally (around the deltoid) as it translates. • Incompetent ATFL => Excessive anterior translation relative to other side * Acute laxity does not correlate with development of late symptoms = does not always require surgery

Are RADIOGRAPHS indicated? MRI • Ottawa rules • Not required in the ACUTE setting •FOOT X-rays • Considered for the patient with chronic pain (>6 • Navicular tenderness weeks) after ankle sprain • 5th metatarsal base tenderness • Useful for assessing concomitant pathology • Both immediate inability to WB and not able • 90% accuracy for ATFL and CFL tears to walk more than 4 steps in ED • Does not give an absolute indication for surgery

4 Clinical Classification Grade I Grade II Grade III

• Mild Sprain Edema, Localized, Localized, Diffuse, slight moderate significant • Able to walk without limp ecchymosis • Minimal swelling or point tenderness Full or Difficult Impossible partial without • Pain with reproduction of mechanism of injury Weight bearing without crutches significant • Moderate Sprain pain • Walking with a limp Ligament Ligament Partial tear Complete tear • Localized swelling with point tenderness pathology stretch (ATFL) (ATFL + CFL) • Unable to rise on toes or hop on injured ankle Instability testing None None or slight Definite • Severe Sprain (anterior drawer) • Prefers crutches and has difficulty bearing weight Time to return to 11 days 2-6 weeks 4-26 weeks sport • Diffuse tenderness and swelling

• Mainstay of treatment is nonoperative Treatment – Acute Ankle Sprain management, even in the athletic population • P.R.I.C.E • Protection • Rest • Ice • Compression • Elevation • Progressive weightbearing as tolerated • Early range of motion • Physical Therapy – functional ankle rehabilitation

5 Treatment – Acute Ankle Sprain Treatment – Acute Ankle Sprain

• Bracing • Bracing • Protection from inversion to prevent weaker type III • Semi-rigid ankle support: shorter time collagen  elongation to return to work & sport, less • 3 weeks  collagen starts to mature, controlled stress on the ligament promotes proper collagen symptomatic instability at short-term orientation follow-up Grade 3 • Functional Rehabilitation Grade 1 & 2 • Ankle motion, stretching and strengthening will avoid harmful effects of immobilization on muscle, joint cartilage, and bone

• Full return to activities between 4-8 weeks

The Ankle Sprain The Ankle Sprain • Functional Rehabilitation • Achieve full ROM • Peroneal tendon strengthening and • Grade I and II  good to excellent proprioception • Gradual progression of weightbearing and return to play • Grade III  a little more controversial

• Supervised PT has better outcome with regard to strength and proprioception in the short term • Reinjury rates and long term functional results similar to home therapy plans

6 Acute Sprain Chronic Instability Operative Indications for Lateral Ankle Reconstruction • 10-20% risk after ankle sprain • Two types • Continued pain and instability despite extensive • Mechanical non-operative management • Abnormal clinical laxity • pathologic hypermobility of the tibiotalar joint • Must rule out and/or treat other pathology • Sign • Functional • Subjective instability • unreliable ankle, no demonstrable radiographic signs of instability • Symptom

Surgical Management of Return to Play after Lateral Lateral Ankle Instability Ligament Reconstruction • Anatomic reconstruction • Outcomes of athletes after Brostrom • Modified Brostrom lateral ligament • 58% returned to preinjury level reconstruction • 16% competing at a lower level • Allograft lateral ligament reconstruction • 26% discontinued sport but still active • (Maffulli et al, AJSM 2013)

7 Rehab and Recovery after Clinically significant late Reconstruction pain after ankle sprain • Phase I – ROM • Clinically significant pain >6 weeks after injury • Phase II – Endurance without recurrent injury or instability • Phase III – Strength • Phase IV – Power • Consider pathology that may be in conjunction with an ankle sprain or consider a • Phase V – Return to Sport Testing and Physician different diagnosis Clearance • Achieve 90% of contralateral limb strength • Soft tissue lesions

• Bone / articular lesions

Soft Tissue Lesions Soft Tissue Lesions • Anterolateral soft tissue impingement • Peroneal tendon tear

• Complaint: focal anterolateral pain, worse with • Complaint: focal lateral pain, worse dorsiflexion and cutting maneuvers with eversion • Exam: swelling, focal lateral • Exam: focal anterolateral ankle tenderness tenderness, pain with eversion

• Treatment: steroid injection; arthroscopic debridement

8 Soft Tissue Lesions Soft Tissue Lesions • Peroneal tendon tear • Peroneal tendon subluxation • Treatment: NSAID/immobilization, lateral heel wedge, • Complaint: pain and snapping of tendons over fibula surgical debridement or repair if no response • Exam: swelling, focal ttp posterior to distal fibula, dislocation of tendons with resisted eversion

Soft Tissue Lesions Soft Tissue Lesions • Peroneal tendon subluxation • Sinus tarsi syndrome • Treatment: fibular groove deepening and retinacular reconstruction • Complaint: pain and swelling lateral hindfoot, exacerbated on uneven surfaces • Exam: swelling, focal ttp anterior to distal fibula • Treatment: NSAID/immobilization, steroid injection, arthroscopic debridement

9 Syndesmotic Injury – High Soft Tissue Lesions Ankle Sprain • Syndesmotic injury • Collision sports, 10% of all ankle sprains • Complaint: pain in distal leg and ankle with • Mechanism: external rotation cutting/twisting • Direct force posterior calf of downed player with • Exam: external rotation stress test; squeeze test foot externally rotated • Xrays/MRI/US: • External rotation force on knee while foot firmly planted • Stress xrays: disruption or widening of syndesmosis

Syndesmotic injury - Treatment Soft Tissue Lesions

• Grade I and II: • Superficial peroneal neuropraxia • RICE, PT, ankle brace or – intermediate branch taping • Grade III: • Acute- ORIF • Complaint: anterolateral pain / burning / (screws/Tightrope) numbness • Chronic- arthroscopic • Exam: focal ttp, + tinels, decreased debridement + fixation sensation dorsolateral foot • Longer time to return to play • Treatment: neurontin / lidoderm patch / and more residual symptoms desensitization than simple ankle sprain • Neurolysis vs. transection

10 Bone / Articular Lesions Bone / Articular Lesions

• Juxta-articular fractures • Juxta-articular fracture • Anterior process of the calcaneus • Complaint: pain swelling in the area of the fx • Exam: focal ttp, pain with provocative maneuvers • Imaging: often apparent on xray but must look closely • Bone scan: hot locally • CT scan: define fragment size and articular involvement to define surgical plan • Treatment: immobilization in cast or boot 4-6weeks • Excision vs. ORIF if large articular fragments

Bone / Articular Lesions Bone / Articular Lesions • Juxta-articular fracture • Posterior talar process (Stieda process) • Juxta-articular fracture • Lateral talar process

11 Bone / Articular Lesions Bone / Articular Lesions

• Juxta-articular fracture • Osteochondral lesion of the talus (OLT) • Dorsal navicular rim avulsion • Complaint: swelling, sharp pain/aching deep in joint, occasional mechanical locking/catching • Exam: focal ttp @medial / lateral shoulder of talus • Distal fibular avulsion • Imaging: xray may show cyst in chronic OLTs, CT/MRI is diagnostic • Cuboid avulsion • Sometimes an incidental finding • If not symptomatic does not require treatment

Bone / Articular Lesions Bone / Articular Lesions

• Osteochondral lesion of the talus (OLT) • Osteochondral lesion of the talus (OLT) • Non-operative management • Surgical Treatment: • Mesenchymal cell stimulation • Non displaced acute lesions • Microfracture, abrasion chondroplasty • Immobilization x 6 weeks • Autograft osteochondral transfer • Allograft osteochondral transfer • Operative Management: • Allograft chondral transfer • Failed conservative care, large and/or displaced • Autologous chondrocyte implantation (ACI) fragments • Juvenile particulated allograft cartilage • Biocartilage

12 Bone / Articular Lesions • 5th metatarsal fractures

• Poor blood supply to zone 2 • Clinically assess for: • Area(s) of tenderness Zones: • Cavovarus foot posture • Chronicity of fracture 1= tuberosity avulsion (sclerosis or periosteal fractures (may enter 5th MT- reaction) cuboid articulation) 2= Jones fractures (metaphyseal-diaphyseal junction) 3= stress fractures (distal to 4/5 IM ligaments, extends distally into diaphysis for 1.5cm)

Zone1- 5th MT tuberosity Jones Fracture avulsion fractures • Treatment usually hard-soled shoe or boot • 4 wks usually patients asymptomatic • Time to healing approximately 8 wks • Symptomatic nonunion- excise fragment

13 5th Metatarsal Jones fracture Jones fracture

• Non-displaced fractures: Nonweightbearing cast or boot 6-8 wks • Consider surgery if: • Displaced fracture • Athlete • Quill 1995: 25-50% of fractures treated closed found not to heal or to re-fracture • Delayed union or nonunion:

• Return to play @8-10wks post ORIF if radiographically healed fracture

Bone / Articular Lesions Bone / Articular Lesions • Tarsal coalition • Anterior impingement • “Footballer’s ankle” • Complaint: recurrent ankle sprains in the adolescent, • Runners and jumpers lateral hindfoot pain • Pain, localized anteriorly • Exam: rigid subtalar motion • Limited ROM • Imaging: • Xrays: exostosis distal tibia (usually lateral), cupping of talar • Calcaneonavicular bar neck +/- spur • Talocalcaneal coalition • Treatment • Treatment: immobilization always first step • Conservative: ↓ activity • Resection/arthrodesis depending on size and location of • Surgery if persistent symptoms refractory and xray evidence of impingement

14 Metatarsal stress fractures Navicular Stress Fractures • “March” fractures • Exam: • Military recruits or dancers frequently affected • Dorsomedial vague pain, • Increase in duration or intensity of exercise prolonged symptoms • 2nd MT involved more commonly than 3rd MT • Positive percussion test over • Fatigue-type fractures navicular • Point tenderness over affected metatarsal (not web) • Limited motion of subtalar joint • Circumscribed swelling over dorsal foot that does (50%) not extend to medial or lateral border of foot • Pain generated in navicular area • Initial xrays usually negative when patient stands on toes • Treatment: hard-soled post-op shoe, cessation of • Often xrays negative: inciting activity • Bone scan sensitive, CT • Recovery variable: usually return to normal shoewear by determines fx location and 6-8wks extent, MRI shows early edema • Shoe modification with orthosis

Navicular stress fracture Stress fractures • Incomplete or nondisplaced fractures: • MRI – most accurate test for suspected lower • Cast and nonweightbearing for 6 wks extremity stress fractures • Protected WB for 6 wks • RTP avg 4 months; +/- orthotic with medial • Meta-analysis longitudinal arch support • Radiographs (sensitivity 12-56%) • Operative treatment considered: • Bone Scans (sensitivity 50-97%) • Complete fractures with sclerosis • CT scans (sensitivity 32-38%) • Displaced fractures • Ultrasound (sensitivity 43-99%) • ?High-demand athletes with nondisplaced fractures • Quicker RTP (83% healing, RTP 3.6mos vs • MRI (sensitivity 68-99%) 5.6mos) • Persistent symptoms or failed conservative treatment – Wright, et all Am J Sports Med 2016

15 Achilles Tendon Rupture Achilles Tendon Rupture • Dual blood supply • Complete disruption of Achilles tendon • Muscles above • Location • Bony attachment below • Often 5-7 cm above insertion to heel • Watershed zone bone – 1-4 inches above tendon • Commonly affected attachment to heel bone • Middle aged (average age in 40s) • Men (M:F ~3:1) • “weekend warriors”

Achilles Tendon Rupture Achilles Tendon Rupture

•History •Examination • Mechanism of injury • 20-30% delayed diagnosis • Eccentric loading (pushing off) • Pop • High clinical suspicion • “someone hit the back of my ankle” • Inability or difficulty walking • Thompson Test • Pain behind ankle • Gap sign • Possible association with • Loss of resting equinus • Prodromal symptoms • Recent fluoroquinolone use • Recent steroid use

16 Achilles Tendon Rupture Achilles Tendon Rupture •Examination •Examination • Thompson Test

Achilles Tendon Rupture Achilles Tendon Rupture

•Imaging – not usually required • Initial Treatment • Xrays • Immobilize in plantarflexion • May rule out fracture • Keep nonweightbearing with crutches • RICE therapy • MRI • Counsel on signs and symptoms of DVT • Helpful for delayed presentation or equivocal clinical exam • U/S • Inexpensive, can confirm diagnosis and localize tear

17 Achilles Tendon Rupture Achilles Tendon Rupture

• Treatment •Treatment • Controversial • Nonoperative • With early diagnosis and immobilization, may •NOT a passive treatment program achieve similar results •Immediate immobilization in plantarflexion • Management depends on surgeon and patient •Progression to formal Physical preference Therapy for functional rehab after 2 weeks • May favor surgery for athletes, younger –Transition to boot with 2cm heel patients, and delayed diagnosis with lift diastasis of tendon ends –Progressive return to weightbearing and controlled strengthening

Achilles Tendon Rupture Heel Pain – Plantar Fasciitis •Treatment • Most common cause of plantar heel pain  Operative • Peak age of incidence between 40-60 years • Multiple options • Risk factors include runners, prolonged • Open standing, obesity, limited dorsiflexion of the • Limited incision ankle • No significant differences confirmed between methods

18 Plantar Fasciitis Plantar Fasciitis • History •Examination • Insidious onset without trauma • Pain at the medial tubercle of the • Typical pain with start up or initiation of calcaneus weight bearing • First thing in the morning or after sitting for periods of time (watching TV, driving, eating) • Typically lessened or not symptomatic during activity • Often recent increase in activity or change in shoe wear

Plantar Fasciitis Plantar Fasciitis • Differential • Differential • Neurogenic (tarsal tunnel, peripheral neuropathy, • Calcaneal stress fracture radiculopathy) • Specific onset of symptoms • Pain may not be specific to the medical calcaneal tuberosity • Constant pain • Patients often report burning and tingling pain • Tender on both sides of the heel • Tinel’s sign • Worse with weight bearing • Radiating symptoms • Present on plain radiographs • Lack of focal symptoms to exam Stress • Not specific to weight bearing Fracture Tarsal Tunnel

Plantar Fasciitis Plantar Fasciitis

19 Plantar Fasciitis Plantar Fasciitis • Treatment • Treatment - Nonoperative • Non-operative treatment • Majority of patients >90% will improve with non- • Injections operative treatment • Cortisone • Tissue specific plantar fascia stretching • Platelet rich plasma • Achilles stretching • Limited studies documenting its • Heel cups efficacy • Over the counter orthotics • Extracorporeal shockwave treatment • Night splints • NSAIDs • High and low energy options • Well tolerated • Immobilization • Cam boot 2-4 weeks

Plantar Fasciitis Hallux Valgus - Bunions •Treatment – Surgical • Recalcitrant cases > 12 months • Common causes •Extrinsic •Plantar fasciotomy –Inappropriate shoegear • Open or endoscopic •Intrinsic techniques –Hereditary »Incompetent soft tissue restraints • Assess lateral plantar nerve »Generalized joint hypermobility •Achilles or Gastrocnemius »Predisposing bony anatomy lengthening

20 Hallux Valgus - Bunions Bunions • Conservative Therapy is always the first • Surgical Treatment line • Symptoms that persist despite nonsurgical treatment • Operate on the shoe • Factors to consider • Pads, Spacers • Existence of arthritis or arthrosis • Degree of deformity and passive correctability • Patient expectations • May potentially discourage surgery in • Athletes not willing to potentially give up sports • Women wanting to constantly wear high heels with narrow toe boxes

Bunions • Minimally Invasive • Traditional • Surgical Treatment • Requires Osteotomy (cutting and resetting) or Fusion

21 Ankle Arthritis Ankle Arthritis • Symptoms • Etiology • Band of pain and swelling around ankle • Osteoarthritis is not the most common • Limited motion (loss of dorsiflexion more etiology common) • Trauma • Possible deformity • Inflammation • Gait disturbance / Limp • Infection • Instability

Ankle Arthritis Ankle Arthritis • Xrays • Nonoperative Treatment • Loss of joint space • Activity modification • Periarticular osteophytes • NSAIDs • Subchondral sclerosis and cysts • Bracing • Rocker bottom shoes • Injections

22 Ankle Arthritis Ankle Arthritis • Surgical Treatment • Surgical Treatment • Arthroscopic/ open debridement • Tibial osteotomy • Bone and soft tissue impingement • Tibial/ calcaneal osteotomy • Distraction arthroplasty • Allograft replacement • Arthrodesis • Total ankle replacement

Ankle Arthrodesis Total Ankle Replacement • Ideal patient • Reasonably mobile • Middle-to-old aged patient • Normal or low BMI • Good bone stock • Minimal deformities • Multiple joint arthritis • Rheumatoid arthritis • No neurovascular impairment

23 Summary

• Treatment of foot and ankle conditions can prove quite complicated • impact quality of life • minor foot and ankle problems can turn into big ones • We provide comprehensive care responsive to current and long-term patient needs • Most problems can be treated effectively without surgery

• Forefront of orthopaedic technology, offering cutting- edge techniques and developing new procedures for difficult problems

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